Developing Safety Programmes in
Regional Hospitals
PSC & PIPSQC Paediatric Patient
Safety Day
Birmingham, May 20th 2013
Dr. John FitzSimons
HSE Ireland
Dr. Santanu Maity
Royal Free Hospital, London
At the end of this session you will be able to….
• Discuss some of the unique features of paediatric patient
safety
• Understand the challenges when developing paediatric
patient safety in a regional centre
• Plan strategically for paediatric patient safety
• Describe some proven safety solutions and know how to
implement them
What is patient safety?
“The avoidance, prevention and
amelioration of adverse outcomes or
injuries stemming from the process of
healthcare”
Charles Vincent
A Story…
Organisational Accident Model
Organisation
& Culture
Contributory
factors
Environment
factors
Management
decisions
&
Organisational
processes
Care delivery
problems
Unsafe acts
Team factors
Errors
Staff factors
Task factors
Violations
Patient factors
Latent
failures
Defences &
Barriers
Active
failures
Harm
Errors of Omission
“On average, children received 46.5%
of the overall indicated care”
Error & Harm
Non-preventable
Error
Harm
Preventable
Group Discussion 1
What makes paediatric patient safety
different?
Patient Factors
Unique Features of Paediatric Care
Difference (4 D’s)
Development
- Physical
Safety implication
- Psychological
e.g. age weight changes, changes in
pharmacokinetics, Increased susceptibility to
infection
- Emotional
Communication, consent
Dependence (on adults)
Wrong details, various people giving meds etc
Consent
Different disease
epidemiology
Rare diseases – rare treatments
Demographics
Poverty, language barriers
System Factors
System
Factors
Adult setting
Paediatric setting
Team
Interchangeable (e.g.
hospital at night)
Specific
Tasks
Routine
Adapted around patient
Tools &
Technology
Standardised. Designed for
adults
Patient specific. Adapted
from adults
Work
environment
Designed for adults
Built for medicine past
Often share adult
resources, labs, radiology
Organisation
Larger
Smaller. High profile
NPSA Safety incident reports
(Children Vs Adults)
Problem
Medication
Children
19%
Adults
9%
Treatment/procedure
problem
Device problem
14%
7%
6%
3%
Consent issue
7%
4%
Patient accident
13%
41%
Safety Solutions
“We cannot change the human condition,
but we can change the conditions under
which humans work”
James Reason
Group Discussion 2
What are the challenges for paediatric
patient safety in a regional setting?
Some Challenges for Paediatric Patient
Safety in Regional Settings
• Small units, fewer staff
• Paediatrics usually left until “we get it right elsewhere”
• Many services are shared:
- A&E, OPD, Theatre
- Surgery & Anaesthetics (and their trainees)
- Diagnostics (Laboratory & radiology)
- Allied professionals
- Pharmacy
• Most research comes from children’s hospitals
Group Discussion 3
What would a safe paediatric service
look like in your hospital?
Harm Free Paediatrics
1. No, or the very least, pain or distress.
2. No unnecessary investigations or admissions or
treatments.
3. No tissue injury - extravasation, pressure or
other.
4. No hospital acquired infections.
5. No medication or fluids injuries.
6. Recognise sepsis or other life threatening events
as early as possible and institute the right
treatment.
7. Safeguarding with safe care
Make Space for Improvement
“Here is Edward Bear, coming
downstairs now, bump, bump,
bump, on the back of his head.
It is, as far as he knows, the
only way of coming
downstairs, but sometimes he
feels that there really is another
way, if only he could stop
bumping for a moment and
think of it.”
Winne the Pooh
A.A. Milne
Dr. John Fitzsimons
First Steps
• Will, Ideas, Execution
• Have an aim – SMART
• Have a strategy – driver diagrams
• Have an improvement method - Model for Improvement
SMART Aim
Specific
Measurable
Achievable
Realistic
Time bound
Aim – “Improve hand hygiene”
SMART Aim
Specific
Measurable
Achievable
Realistic
Time bound
Aim – “Improve hand hygiene for all staff on the
children’s ward to over 90% of cleaning
opportunities by the end of June 2013”
Driver Diagram
Aim
Primary Drivers
(Processes, rules of conduct, structure)
Secondary Drivers
(Components & activities leading to 1º drivers)
Driver Diagram
Primary Drivers
(Processes, rules of conduct, structure)
Crispy Skin
Secondary Drivers
(Components & activities leading to 1º drivers)
Basting
Seasoning
Heat
Moist meat
Brining
Slow & low cooking
flavoursome
Organic chicken
Herbs
Components – Chestnuts, bread
Volume
Perfect Stuffing
Great Gravy
Stock
Wine
flavourings
Good Presentation
Dressing
Plates
The Perfect Roast
Chicken
Driver Diagram
Primary Drivers
(Processes, rules of conduct, structure)
Communication
Medication harm
Improve safety
on children’s
wards
Early detection &
rescue of sick child
Parental involvement
Measure harm & learn
from serious events
Heathcare assoc
infections
Management &
leadership
Secondary Drivers
(Components & activities leading to 1º
drivers)
Handover (SBAR & Critical language)
Photo boards
Proformas for admission
Prescribing criteria
Standardised medication guidelines
Situation awareness (PEWS)
Safety briefings
Improve rescue – Simulation, debriefing, RRT
Transparency
On safety committee/team
Ability to effect change
Become a learning organisation
Institute GTT
SUI team
Rapid reviews
Debriefings
Formal response to all/selected incidence forms
Improve hand hygiene
Surgical site infections
Safety a the top of the agenda
Safety culture
Clear information on safety and harm
Walkabouts
Aim
Measures
Changes
Execution
The Improvement Guide, API
The PDSA Cycle for Learning and Improvement
What change can we make that will result in an
improvement ?
Act
• What changes
are to be made?
• Next cycle?
Study
• Complete the
analysis of the data
•Compare data to
predictions
•Summarize
what was
learned
Plan
• Objective
• Questions and
predictions (why)
• Plan to carry out the cycle
(who, what, where, when)
• Plan for data collection
Do
• Carry out the plan
• Document problems
and unexpected
observations
• Begin analysis
of the data
Repeated Use of the Cycle
Changes That
Result in
Improvement
A P
S D
A P
S D
Hunches
Theories
Ideas
Group Discussion 4
How might you achieve Harm Free
Paediatrics where you work?
A few ideas we’ve tried…
• Situation awareness
• Communication
• Bundles
• Bring consultants to the front 24/7
PEWS Background
• CEMACH report “Why Children Die” found
preventable factors in 26% of reviewed
cases
• Centres with PICU and rapid response
teams have used PEWS to trigger the
team.
• No accepted model
“Brighton” PEWS
PEWS: 24 PDSA Cycles in 9 Months
K
RFH PEWS
• Scores on 7 parameters
• Set actions according to score
0-1 Continue observations
2
Nurse in charge review
3
Above plus SHO review
4
Above plus inform registrar
5-7 Registrar review +/- Crash call
SBAR
Situation
Background
Assessment
Recommendations
SBAR
• Situation
– One sentence description of problem
• Background
– Details that give information
• Assessment
– What you think about the problem
• Recommendation
– What you think needs to be done
SBAR Modifications
• iSBAR – identification of yourself, your
location and your patient.
• SBAR with a Readback – After handover
give a readback of highlights
SBAR Notes
• 11 Essential components of a
hospital note
1. Patient ID
2. Date
3. Time
4. Context
5. Situation
6. Background
7. Assessment
8. Recommendation
9. Signature
10. Print Name
11. Medical Council Number
Improvement Process
•
•
•
•
Education
Prompts
Measurement and feedback
Twice a week, up to 10 charts if
available
- Individual (out of 11)
- Bundle (11 out of 11)
• Changes
- More education
- Individual feedback
- Consultant ownership
Use data to drive Change
% Compliance
SBAR Notes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Education and visual
reminders
Named consultant
Bundle
Re-education and
individual feedback
Wk 1
Wk 2
Wk 3
Wk 4
Wk 5
Wk 6
Wk 7
Wk8/
Dr. A
Wk 9/ Wk 10/ Wk 11 / Wk 12/
Dr B
Dr C
Dr D
Dr E
20-Apr 27-Apr 05-May 09-May 18-May 25-May 30-May 03-Jun 07-Jun 17-Jun 22-Jun 29-Jun
Weeks
25/10/2012
Items
Dr. John Fitzsimons - Presentation to
National Clinical Leads
“To err is human, to cover up is unforgivable,
and to fail to learn is inexcusable.”
Sir Liam Donaldson
Questions welcome